What is the treatment for watery eyes?

Treatment for Watery Eyes

The treatment for watery eyes depends on the underlying cause, but for allergic conjunctivitis—the most common cause of watery eyes—start with environmental modifications and cold compresses, then advance to topical antihistamine/mast cell stabilizers like ketotifen or olopatadine, reserving short courses of topical corticosteroids for severe cases. 1

Initial Assessment and Conservative Measures

Begin with simple environmental and behavioral interventions that apply to most causes of watery eyes:

• Wear sunglasses as a barrier to airborne allergens 1
• Apply cold compresses and use refrigerated artificial tears for symptomatic relief 1
• Avoid eye rubbing, which can worsen symptoms and lead to complications 1
• Use hypoallergenic bedding, eyelid cleansers to remove allergens, frequent clothes washing, and shower before bedtime 1
• Eliminate exposure to cigarette smoke, which adversely affects the tear film 2
• Humidify ambient air and avoid air drafts by using side shields on spectacles 2

Pharmacologic Treatment Algorithm

Mild Watery Eyes (Allergic Conjunctivitis)

For mild cases, start with over-the-counter topical antihistamine/vasoconstrictor agents or second-generation topical H1-receptor antagonists: 1

• Second-generation topical antihistamines are more effective than first-generation agents 1
• Store topical medications in the refrigerator for additional cooling comfort upon instillation 1
• Avoid chronic use of vasoconstrictor agents, as they can cause rebound vasodilation once stopped 1
• Use preservative-free artificial tears when applying more than four times daily to dilute allergens and inflammatory mediators 1, 2

Moderate to Severe Watery Eyes

If symptoms are frequently recurrent or persistent, advance to mast-cell stabilizers or combination antihistamine/mast-cell stabilizing agents: 1

• Ketotifen fumarate 0.025% has rapid onset (within 15 minutes) and extended duration (at least 8 hours), making it highly effective 3
• Ketotifen blocks H1 receptors, stabilizes mast cells, and inhibits eosinophils through multiple mechanisms 3, 4
• In environmental studies, ketotifen showed superior efficacy compared to both placebo and levocabastine in reducing signs and symptoms 4
• Olopatadine 0.1% is another effective option, with some patient preference studies showing higher comfort ratings 5

Refractory Cases

For symptoms not adequately controlled with antihistamines and mast-cell stabilizers, add a brief course (1-2 weeks) of topical corticosteroids with a low side effect profile: 1

• Limit corticosteroid use to 2-4 weeks maximum to avoid complications including prolonged adenoviral infections, worsened HSV infections, glaucoma, and cataracts 1, 2
• Topical loteprednol is preferred as first-line anti-inflammatory corticosteroid 1
• In severe cases, consider topical cyclosporine or tacrolimus for steroid-sparing anti-inflammatory therapy 1

Important Caveats and Pitfalls

Avoid these common mistakes when treating watery eyes:

• Do not use punctal plugs in allergic conjunctivitis, as they prevent flushing of allergens and inflammatory mediators from the ocular surface 1
• Eye rubbing from uncontrolled allergic conjunctivitis increases risk of punctal plug complications including extrusion, canalicular migration, and secondary nasolacrimal obstruction 1
• Oral antihistamines may worsen symptoms by inducing or worsening dry eye syndrome and impairing the tear film's protective barrier 1
• Indiscriminate use of topical antibiotics or corticosteroids should be avoided—antibiotics can induce toxicity and corticosteroids can prolong viral infections 1
• Overuse of preserved artificial tears can cause toxicity to the ocular surface 2

Treating Concurrent Conditions

Address underlying conditions that may contribute to watery eyes:

• Treat concurrent blepharitis or meibomian gland dysfunction with hot compresses, lid massage, and topical or oral antibiotics 2
• Correct eyelid abnormalities such as trichiasis, lagophthalmos, entropion, or ectropion 2
• Recognize and treat demodex blepharitis, which can be an inciting stimulus 1
• Address conjunctivochalasis, exposure keratopathy, and essential blepharospasm as needed 1

Pediatric Considerations

Ketotifen fumarate 0.025% is safe and effective in children ages 8-16 years:

• Significantly inhibits ocular itching at all post-challenge timepoints compared to placebo 6
• Also reduces hyperemia, chemosis, and lid swelling 6
• No drug-related systemic adverse events reported in pediatric trials 6

Follow-Up and Monitoring

Frequency of follow-up depends on disease severity and treatment:

• If using chronic or recurrent corticosteroids, perform baseline and periodic IOP measurement and pupillary dilation to evaluate for glaucoma and cataract 1
• Monitor for keratoconus in patients with allergic conjunctivitis and atopic disease, as adequate control of allergy and eye rubbing are important to decrease progression of ectasia 1